CHAPTER 44 



Blood supply to the heart 



DONALD E. GREGG 

 LLOYD C. FISHER 



Department of Cardiorespiratory Diseases, Walter Reed Army Institute 

 of Research, Walter Reed Army Medical Center, Washington, D. C. 



CHAPTER CONTENTS 



Functional Anatomy 



The Myocardium 



Coronary Arteries 



Myocardial Arterioles and Capillaries 



Myocardial Veins 



Collateral Circulation 



Congenital Anomalies 



The Cardiac Nerves 



Lymphatic Drainage of the Heart 

 Preparations and Methodologies of Special Interest in the 

 Study of the Heart and Its Coronary Circulation 



Preparations 



Coronary Flow Methods (Animals) 



Coronary Flow (Man and Animals) 

 Distribution of Myocardial Blood Flow- 

 Arterial Circuit 



The Venous Circuit 



Possible Use of Left Coronary Artery Flow Together with 

 the Chemical Composition of Coronary Sinus Blood as an 

 Index of Left Ventricular Metabolism 

 Physical Determinants of Coronary Flow 

 Determinants of Normal Myocardial Metabolism 

 Basal Data 

 Response of the Coronary Circulation to Various Stimuli 



Resting State 



Reactive Hyperemia 



Heart Rate 



Heart Doing No External Work 



Ventricular Volume or Fiber Length 



Blood Pressure 



Chemical Composition of the Blood 



Transfusion 



Anemia 



Nervous Influences 



Hormones 



Exercise and Excitement 



Valvular Disease 



Hypertensive Cardiovascular Disease 



Heart Failure 



Hemorrhagic Shock 



Hypothermia 



Hyperthermia 



Summary 

 Drugs Versus the Coronary Circulation 



Coronary Artery Disease 



Natural Responses of the Normal but Overstressed Portion of 



the Myocardium 

 Coronary Artery Collateral Circulation 



FUNCTIONAL ANATOMY 



the historical knowledge of the heart's integral 

 blood supply parallels knowledge of the broader scope 

 of the cardiovascular system in toto. Thus commenc- 

 ing with Galen's designation of the term "coronary 

 arteries," it nevertheless remained for Harvey (1645) 

 to show accurately that channels existed in the walls 

 of the heart for its own nourishment. Interarterial 

 anastomoses were demonstrated by Lower in 1671 

 using fluid injection techniques, and in 1 704 the 

 ventricular branches of the coronary arteries were 

 visualized by a corrosion technique introduced by 

 Ruysch. Connections between the arteries and the 

 cardiac cavities were shown in 1 706 by Vieussens 

 using saffron injections into the coronary arteries, and 

 between the cardiac veins and the cardiac chambers 

 in 1 708 by Thebesius using air injected through the 

 coronary sinus. That these cavitary communications 

 were, in fact, different channels was not well docu- 

 mented until the twentieth century when phylo- 

 genetic studies by Grant (142), and mammalian 

 studies by Wearn (382) established the existence of 

 intramyocardial trabeculae and sinusoids which 

 separated the veins (Thebesian) from the arterial 

 circuit (arterioluminal), and contributed their own 

 communications (arterio-sinusoidal) to the cavities. 

 The more recent introduction of radiographic tech- 

 niques (84, 352) for visualization of coronary arteries 

 in intact humans and animals, or in pathologic speci- 

 mens (18, 37, 338), and of cast-digestion techniques 

 (18, 172, 173, 190-192, 258) for permanent reproduc- 



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